HomeMy WebLinkAboutCC 4 CLAIM #89-15 07-17-89 CONSENT CALENDAR
· '~=~ .... ~ ~ ~. . ..... ~,., NO. 4
DATE: JUNE 16, 1989 ~~~ IRK~r~~~
JUU 2 0
TO:
HONORABLE MAYOR AND CITY COUNCIL
CITY ATTORNEY
S UBJ ECT:
CLAIMANT: EDWARD HANSEN; D/L: 2/1/89; DATE FILED W/CITY:
5/16/89; CLAIM NO: 89-15; CARL WARREN FILE NO: S 57874 PRB
After investigation and review it is recommended that the above-
referenced claim be rejected and the City Clerk directed to give
proper notice of the rejection to the claimant and to the
claimant's attorney.
City Attorney
- .-
JGR (F 4. se )
Enclosure: Copy of Claim
CLAIM AGAINST THE CI~v OF TUSTIN
('For Damages to Per: :or Personal Property)
Received by via
U.S. Mail
Inter-office Mail
Over the Counter
the City of Tustin within 100 days after which the incident or event occurred
Be sure your claim is against the-City of Tustin, not another public entity.
Where space is insufficient, please use additional paper and identify informs
tion by paragraph number. Completed claims must be mailed or delivered to tk
CLt'_.__~_; Clerk, The City of Tustin, 300 Centennial Wa_~/_Tustin, California 92680
TO THE HONORABLE ~{AYOR AND CITY COUNCIL, City of Tustin, California:
The undersigned respectf,,~lly submits the foilo~¢ing claim and information rela.
tire to damage to persons and/or personal property:
I. NAME OF CLAIMANT: /3 ~ /
a. ADDRESS OF CLAIMANT'.: /-~ ~ ":~ ~ ~'~', ~ ~ ~
b. PHONE NO. (
, ' c. 'DATE OF BIRTH:
DRIVERS
· · . ' ~ ~ e ~fCENSE NO: %~
2. Name, telephone an~ post office address to which claimant desires notices
to be sent, if other than above:
~. This claim is submitted against:
a. ~ The City of Tustin'-only.
b. /
The following employee(s) of the City of Tustin only:
,.
C ·
The City of Tustin and the following employee(s) of the
City of Tustin on. ly:
Occurrence or event from which the claim arises:
a DATE: ?:?,' .Jj~ /~:/.~,~ //' ~1~'~/
· _ , ~,0~. 'TIME:
c~ PLA=~CE (Exac,~
and specific location): '/~:'~':': ~" ~"~:~ ~ ' ,A> ~ ' .' .~
d. How and under what circumstances did damage or injury occur? Specify
the particular occurrence, event, act or omission you claim caused
the inj. ury or damage (Use additional paper if necessary)·
I
e. What particular action by the City, or its emploYees, caused the
alleged damage or injury? ·
5. Give a description : the injury, property d ge 'or loss so far as is
known at the time this claim. If there w, -. no injuries, state "no
injuries".
·
6. Give the name(s) of the City employee(s) causing the damage or injury:
~ .,.." ',' r ',..,*' ,, ·
7. Name and address of any other person injured:
8._ Name and address of the owner of any damaged property:
9. Damages claimed:
a. Amount claimed as of this date: .//' .
b. Estimated amount of future costs:
c. Total amount claimed:
d. Basis for computation o~ ....... ameunts c~a~.~_.Jd ~include copies of a__~ 'bil~s,
invoices, estimates, etc.:
10. Names and addresses of all witnesses, hospitals, doctors, etc.:
a.
'
o
· ,
¢.
·
11. Any additional information tha~ might be helpful i.n considering this claim:
·
·
WARNING: IT IS /~ CRIMINAL OFFENSE T.O FILE A FALSE CLAIM'. (Penal Code
Section 72; Insurance Code Section 556.0)
I have read the matters and statements made in the above claim and I know the
same to be true of my own knowledge, except as to those matters stated to be
upon information or belief and as to such matters I believe the same to be true.
I certify under penalty of perjury that the foregoing is TRUE AND CORRECT.
Executed this ,,/.~-- day of ~'pi!
i
Office of the City Clerk,
Tustin, California
· 19 ~ , at Tustin, California.
CLAIMANT'S SIGNATURE
CLAIM NO:
DATE FILED:
.,evised 8/05/81
JGR:se:R:8/5/81 (A)
ED~
(714
1310 F.. IIAINI~R: AVE.
ORANGF., CA 92~'
714,.232.1254
..' ORDER NO
WHeN SHIP
IBUYER
IHOW SHI~·
i
RE~~ 5L500/01500
1
CARBONLESS
13582 SUSSEX PL,
SANTA ANA, CA 92705
LIC .','¢ B-331257